Regency House Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Regency House Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF851Aug 1, 2025

  Based on review of facility documents and staff interviews, the facility failed to ensure weekend staffing was reported correctly to the Payroll Based Journal (PBJ) for quarters 3 and 4 in 2024. The findings include:The PBJ Staffing Data Report labeled Fiscal Year (FY)Quarter 3, 2024 (4/1/2024-6/30/2024) and FY Quarter 4 (7/1/2024 -9/30/2024) indicated the staffing reported by the facility for quarter 3 and 4 in the year of 2024 was considered Excessively Low Weekend Staffing.An interview with the Administrator on 7/28/2025 at 10:20 AM indicated corporate managers submit the facility's PBJ staffing and had been focused on finding the reason(s) why weekend staffing as reported for quarter 3 and 4 were considered by the PBJ system as Excessively Low Weekend Staffing. […]

• No harm, potential for more than minimal, patternF812Oct 10, 2023

  Based on observations, review of facility policy, and interviews, the facility failed to ensure food items were appropriately dated to reflect the opening date and/or the used-by date. The findings include: A tour of the Dietary Department on 10/2/23 at 9:55 AM with the Food Service Director identified food items that were opened and undated without the benefit of a use by and/or discard date. The walk-in refrigerator contained open containers/bottles of barbeque sauce, coleslaw salad dressing, balsamic salad dressing, sweet relish, mayonnaise and maraschino cherries. […]

• No harm, potential for more than minimal, patternF695Jul 27, 2021

  Based on observations, clinical record review, and interviews for two of six residents (Resident #43, Resident #78) reviewed for respiratory care, the facility failed to ensure the oxygen tubing was dated to identify the date it was last changed. The findings include: A) Resident #43's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #43 had severe cognitive impairment and received oxygen therapy. The Resident Care Plan (RCP) dated 11/9/2020 identified Resident #43 had [CONDITION(S)] and shortness of breath. Interventions directed oxygen at two (2) liters (L) via nasal cannula/facemask. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF761Jul 27, 2021

  Based on observations, and interviews for medication storage review, the facility failed to ensure cleaning supplies and personal supplies were stored appropriately, and the facility failed to ensure multidose medications were dated when opened, and the facility failed to ensure expired medications were removed from the medication cart. The findings include: a. Observation and interview with the ADNS on 7/26/2021 at 11:30 AM identified that the first floor Medication Room bottom cabinet contained a half-full gallon size jug of white distilled vinegar with the expiration date of 2/2021 (5 months prior to the observation), a bottle of crystal odor, a bottle of protein stain and an odor, and a bottle of soft scrub, ten (10) ounces with no expiration dates. […]

• No harm, potential for more than minimal, patternF880Jul 27, 2021

  Based on observations, facility policy review, and interviews, for facility infection control review, the facility failed to disinfect the facility glucometer after resident use in accordance with facility policy. The findings include: Observation and interview with LPN #1 on 7/26/21 at 11:20 AM identified LPN #1 took the Assure Prism Multi Blood Glucose Monitoring System (glucometer machine that tests blood sugar levels) from her medication cart and proceeded perform a blood glucose test for Resident #27. Upon completion of the blood glucose test, LPN #1 returned to her medication cart and utilized a Super Sani Cloth wipe (purple top) to wipe down the glucometer. […]